Wiki How would you code this? Distal clavicle injury.

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Orthocoderpgu

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Patient had a shoulder injury. Physician labeled this as a "Distal Clavicle Derangement"

Surgery was performed open. Doc found a loose piece of bone and removed it and then debrided the end to smooth it out. So other than removing the loose piece of bone it's the same as an open Mumford procedure.

Not sure that I have come up with anything that I like as far as coding yet. Thinking more on the lines of a distal clavicle fracture, but hesitate to do that since the physician did not document a fracture.

Any suggestions?
 
CAADM said:
is a derangement similar to an impingement?
Click to expand...
Interestingly enough though, when I look up the definition of a shoulder derangement, shoulder impingement pops up all over the place. However, I honestly think the term "derangement" is too broad, and could be for any issues causing complications in the shoulder.

Here is a medical definition:
Derangement is defined as an internal disturbance in the normal resting position of the joint that results in pain and movement obstruction.
 
I would query the physician if you’re not sure what he mean by derangement. Also, the documentation you provided is not enough to know what he really performed. Your diagnosis should match your cpt code.
 
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